Spine fractures

Spine fractures are injuries involving disruption of one or more vertebrae and may affect the spinal cord, nerve roots, or surrounding ligaments. They represent one of the most serious consequences of trauma because they can lead to permanent neurological disability including paralysis.

The majority of spinal injuries are caused by:

• Road traffic accidents (most common worldwide)

• Falls from height

• Occupational injuries

• Sports trauma

• Violence and assault

• Gunshot wounds

Improper handling and transfer of trauma victims is a major contributor to secondary spinal cord damage. Many patients develop paralysis after rescue, not at the time of injury.

Cervical spine injury is frequently associated with traumatic brain injury; therefore every head-injured patient must be assumed to have a cervical spine injury until proven otherwise.

Mechanisms of Injury

Spinal fractures occur due to energy transfer producing:

• Hyperflexion injury

• Hyperextension injury

• Axial loading (diving accidents)

• Rotational injuries

• Compression forces

• Penetrating trauma

Classification of Spine Fractures

By anatomical region

• Cervical spine (C1–C7) — highest mortality risk

• Thoracic spine (T1–T12)

• Lumbar spine (L1–L5)

• Sacral fractures

By stability

Stable fractures

• No neurological deficit

• Ligaments intact

Unstable fractures

• Vertebral displacement

• Ligament rupture

• Spinal cord injury

Signs and Symptoms

Symptoms depend on injury level and spinal cord involvement.

Local symptoms

• Severe back or neck pain

• Tenderness over spine

• Muscle spasm

• Limited movement

• Deformity

Neurological symptoms

• Weakness of limbs

• Numbness or tingling

• Loss of sensation

• Loss of bladder or bowel control

• Priapism (severe spinal cord injury sign)

• Paralysis (paraplegia or quadriplegia)

Red flag signs (spinal cord compression)

• Progressive neurological deficit

• Saddle anesthesia

• Urinary retention

• Hypotension with bradycardia (neurogenic shock)

Diagnostic Criteria

Diagnosis is suspected when the following are present:

• History of trauma

• Neck or back pain

• Neurological deficit

• Altered consciousness after trauma

• High-risk mechanism of injury

Important rule:Any unconscious trauma patient is assumed to have a spinal injury until ruled out.

Investigation

Initial imaging

• X-ray spine (AP and lateral views)

Definitive imaging

• CT scan (gold standard for bone injury)

• MRI (mandatory for spinal cord, ligament, disc injury)

Additional investigations

• Neurological examination (ASIA score)

• Bladder scan for urinary retention

• Full trauma imaging in polytrauma patients

Treatment

Management priorities:

1. Prevent secondary spinal cord injury

2. Maintain oxygenation and perfusion

3. Stabilize the spine

4. Early referral for definitive care

Pre-hospital Care (Critical Step)

• Do NOT move patient unnecessarily

• Immobilize spine at the scene

• Log-roll technique only

• Transfer on spinal board

Improper transport is a major cause of paralysis.

Non-Pharmacological Management

• Immobilize neck using cervical collar

• Use sandbags or pillows if collar unavailable

• Flat bed or air mattress positioning

• Log-rolling for turning patient

• Prevent pressure sores

• Catheterization for urinary retention

• Treat shock

• Immediate referral to spine surgery center

Surgical management

Indicated in:

• Unstable fractures

• Cord compression

• Progressive neurological deficit

• Vertebral dislocation

Common procedures:

• Decompression laminectomy

• Spinal fusion

• Instrumentation using rods, screws, cages, plates

Pharmacological Management

Initial stabilization

• Oxygen therapy

• IV fluids for spinal shock

Pain control

• Paracetamol

• Opioids if severe pain

Additional care

• DVT prophylaxis

• Pressure sore prevention

• Antibiotics if open injury

(High-dose steroids are no longer routinely recommended in most modern guidelines due to limited benefit and complications.)

Complications

• Permanent paralysis

• Respiratory failure (high cervical injury)

• Neurogenic shock

• Pressure ulcers

• Deep vein thrombosis

• Chronic pain

• Bladder dysfunction

• Sexual dysfunction

Prevention

• Road safety enforcement

• Helmet and seatbelt use

• Fall prevention programs

• Workplace safety equipment

• Safe diving education

• Proper trauma transport training